2-06: Viral Conjunctivitis

Clinical Summary

Viral conjunctivitis is a common presentation of the red eye. Findings are mild and include a thin watery discharge, crusting in the morning, burning or irritation, conjunctival injection (typically diffuse), and lid edema. The tarsal conjunctiva may appear bumpy secondary to hyperplastic lymphoid tissue (follicles). Preauricular adenopathy may be present. The visual acuity is normal. The infection usually begins in one eye, but both eyes usually become involved due to autoinoculation. There are few to no systemic complaints. Adenovirus is the most common virus. A point-of-care test now available may help clinicians to avoid empiric antibiotic therapy.

Epidemic keratoconjunctivitis (EKC) is a severe and highly contagious adenovirus infection that also involves the cornea. Additional features may include foreign-body sensation, photophobia, and pseudomembranes overlying the palpebral conjunctiva. By the 8th day, a painful punctate keratitis that stains with fluorescein may develop; by the end of the 2nd week, these are replaced by white macular subepithelial infiltrates located in the central cornea (that no longer stain). These may cause a decrease in visual acuity, but eventually resolve spontaneously.

Pharyngoconjunctival fever, usually caused by adenovirus type 3, is highly contagious and should be considered if there is associated upper respiratory tract infection and fever.

Management and Disposition

Viral conjunctivitis is self-limited and usually mild. Warm or cool compresses may be helpful. Careful hand washing by patient and staff is important. Over-the-counter topical antihistamines (pheniramine/naphazoline ophthalmic) may provide symptomatic relief. The eye irritation and discharge should improve after 5 to 7 days, but may take 2 to 3 weeks for complete resolution of all symptoms. Antivirals and antibiotics are ineffective. Patients with keratitis should follow up with an ophthalmologist.

Pearls

1. A nonspecific adenovirus conjunctivitis will improve after 5 to 7 days and resolve in 10 to 14 days, but a virulent adenovirus causing EKC will peak in 5 to 7 days and may last 3 to 4 weeks.

2. Consider and rule out serious causes of red eye (acute ACG, iritis).

3. Frequent hand washing and the use of separate linens are advised for patients and family members.

4. Fastidious hand and equipment hygiene is necessary to prevent nosocomial transmission, as adenovirus can be recovered for extended periods of time from these surfaces.